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Advances in diagnosis, treatment of influenza failed to alter its severity in pediatric cancer patients
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Advances in the management of pediatric cancer and influenza since the 1970s have not changed the epidemiology and outcome of influenza in oncology patients, according to study results published online.
To assess how supportive therapy for pediatric oncology patients has improved in tandem with progress in the treatment and prevention of influenza, researchers reviewed the epidemiology, clinical features and outcomes of recent cases of influenza in 102 pediatric patients undergoing cancer therapy at St. Jude Children’s Research Hospital in Memphis, Tenn.
“Influenza-attributable mortality among children and young adults with cancer has remained relatively stable in the past several decades, but influenza continues to cause considerable morbidity,” the researchers wrote. “The ability to identify patients at high risk of serious complications of influenza (those who are neutropenic, have concurrent respiratory infections or who have undergone [hematopoietic stem cell transplantation]) may facilitate a risk-adapted approach to management — aggressive treatment and supportive care for those at high risk of serious disease while minimizing the duration of hospitalization and therapeutic interruptions in low-risk patients in whom other serious illnesses have been excluded.”
During the study period, researchers observed 12 patients (11%) who experienced coinfections with influenza and one or more other respiratory pathogens. Influenza was found to prompt patients’ hospitalization during 64% of episodes, and 75% of the patients received antiviral therapy. Complications were observed in 30% of infections and serious complications occurred in 7% — three patients who had undergone hematopoietic stem cell transplantation died, but these cases were not found to be directly attributable to influenza.
Most patients experienced delays in cancer therapy with a median delay of 5 days. Neutropenia, concurrent infection, increasing age and having received hematopoietic stem cell transplants significantly increased the risk for serious complications.
“This study demonstrated that advances in the treatment of pediatric cancer and in the diagnosis and treatment of influenza have had little impact on the severity of influenza in pediatric cancer patients,” the researchers wrote. “In fact, the low prevalence of influenza and lack of directly attributable influenza-related deaths, in light of a more intensively treated population may suggest that, if anything, risk is lower and outcomes may be better.”
Sixty-five percent of infections were caused by influenza A viruses, and the most common influenza symptoms exhibited by patients included fever, cough and coryza. The researchers said 92% of patients experienced fever — including 97% of patients with hematological malignancies — compared with 79% of patients who had undergone hematopoietic stem cell transplants. In addition, clinical symptoms were similar across patients with different cancer diagnoses.
“A larger proportion of patients who underwent [hematopoietic stem cell transplants] experienced serious complications during their episode of influenza than did those in other groups and the only deaths in this study occurred in transplant recipients,” the researchers wrote. “A greater proportion of patients with neutropenia and a greater proportion of patients who had concurrent infections developed serious complications than patients who did not have these comorbidities. Risk-adapted management plans may reduce the burden of influenza in this population but prospective studies are needed to confirm our findings and identify the optimal strategies.”
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Rabi Hanna, MD, MD
This epidemiologic study demonstrates that, despite the change in our care of oncology patients when they get sick — generally from chemotherapy —patients still have similar outcomes after they get influenza compared with previous studies. This may be explained by prompt diagnosis and early start of antiviral therapy. The researchers also highlighted the difference in morbidity. Despite our ability to take care of these patients, the researchers demonstrated that the patient population is at an increased risk of morbidity, which means an increased hospitalization and delay in chemotherapy.
The researchers also tried to answer if an influenza vaccine could help decrease these complications but, due to the study limitations, they could not answer this question. The study does a good job of identifying risk groups because not all oncology patients are the same. They clearly showed that a patient who underwent bone marrow transplant and a patient who was neutropenic were at higher risk of complications when they suffered from seasonal influenza.
Perspective
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Daniel S. Wechsler, MD, PhD
Delays of less than 2 weeks in administering chemotherapy are quite common, not just from influenza but from other viruses, as well. A 5-day delay — as was the case for this study — is not likely to have a major impact on outcome. Many of the patients who are treated here have acute lymphoblastic leukemia (ALL), and the duration of chemotherapy for ALL is 2½ to 3½ years. A delay of 5 days out of several years is not a cause for concern. However, a time when it might be important is when there is a delay very close to the beginning of chemotherapy. For leukemia, like most cancers, the best chance for dealing with the disease is during the first few months of therapy. We really try to not have delays, even of a couple of days, for the first month or 2 of treatment if we can avoid it. However, if the patient is facing a life-threatening infection, it is totally appropriate to temporarily suspend therapy in order to do what is right for the patient.
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